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Summary

Japanese investigators presented their results on outcomes of conventional transarterial chemoembolization (c-TACE) using guidance software for hepatocellular carcinoma (HCC).

102 patients were included for a total of 190 tumors. Maximum diameter and the number of lesions were 7cm and 5, respectively. Patients who had other types of liver-directed therapy such as DEB-TACE and percutaneous ablation were excluded. Technical success was classified by computed tomography performed 1 week after the procedure (A, complete embolization with a safety margin; B, entire tumor embolization without a safety margin; and C, incomplete embolization). Intrahepatic tumor recurrence was classified into 2 categories: local tumor progression (LTP) and intrahepatic distant recurrence (IDR). The incidences of LTP between grade A and B tumors, IDR with/without LTP, and OS with/without LTP were compared. They found that 156 (82.1%) tumors were grade A, 26 (13.7%) were grade B, and 8 (4.2%) were grade C. The 1-, 3-, and 5-year LTP and IDR rates were 31.7%, 49.4%, and 59.4% and 33.9%, 58.2%, and 73.3%, respectively. LTP developed more frequently in grade B tumors than in grade A tumors (P = .0016). IDR developed more frequently in patients with LTP than without LTP (P = .0004). The overall 1-, 3-, and 5-year OS rates were 96.1%,71.1%, and 60%; the 1-,3-,and 5-year OS rates in patients with LTP was 95.7%, 69.8%, and 59.3%, and 96.2%, 71.6%, and 59.4% in patients without LTP (P = .9984). Authors concluded that guidance software during c-TACE promotes the technical success of the procedure with excellent OS in HCC patients.

Commentary

This paper presents an additional tool to ensure proper lesion targeting during c-TACE for HCC patients.

Selective embolization of all vessels feeding the tumor and adjacent parenchyma is a fundamental requirement to ensure proper tumor response. Although local tumor control did not impact OS in this study, there have been other studies showing that complete tumor response, especially after first TACE, is a predictor of favorable outcome. Therefore, appropriate targeting is critical during the procedure. Given the variance of the hepatic arterial vascularization and exuberant tumoral vessel recruitment commonly seen in HCC, conventional 2D images may not display all the feeding vessels. This study demonstrates the application of guidance software, which highlights all the feeding vessels in a 3D fashion, creating an accurate roadmap for catheter navigation and positioning prior to embolization. In the study, a great majority of lesions (82.1%) presented excellent tumor response (complete embolization of the tumor with safety margin) and these patients had less local and distant intrahepatic tumor progression. One of the limitations of this study was the lack of a control group treated without guidance software to better assess the impact of this new technology. Nevertheless, the study shows excellent results by utilizing this new technology, therefore paving the way for larger comparative studies. Technological advancement and innovation are embedded in our specialty and we should always explore new tools to better treat our patients.